Pulmonary Procedures |

"Plugging" Ends to Get to a Diagnosis! FREE TO VIEW

Tanmay Panchabhai, MD; Debabrata Bandyopadhyay, MD; Abdul Alraiyes, MD; Francisco Almeida, MD
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Respiratory Institute, Cleveland Clinic Foundation, Beachwood, OH

Chest. 2014;146(4_MeetingAbstracts):766A. doi:10.1378/chest.1990022
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SESSION TITLE: Bronchology/Interventional Procedures Cases II

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Monday, October 27, 2014 at 11:00 AM - 12:00 PM

INTRODUCTION: Mucous plugging with fungal disease usually brings ABPA to the diagnostic table. We describe a rare presentation of invasive pulmonary aspergillosis (IPA) limited to airway involvement with mucous plugs which has been called obstructive aspergillus tracheabronchitis (ATB).

CASE PRESENTATION: A 60 year-old black woman with orthotopic liver transplant for hepatitis C presented with dry cough, dyspnea and moderate peripheral eosinophilia (2,290/μL). Only pertinent history was tacrolimus and mycophenolate based immunosuppression and one episode of vomitting. Her O2 saturation was 94% on 2 L/min and examination revealed dullness in the left lower lung. CXR showed the classic “Sail sign” with complete left lower lobe collapse, also seen on CT (Figure I). With a differential of malignancy, aspiration or fungal disease, a bronchoscopy was performed showing complete obstruction of the left mainstem and lower lobe bronchi with a significant burden of mucous plugging which was evacuated by therapeutic techniques like suctioning, Fogarthy’s catheter and cryotherapy probe (Figure II). Bronchial cultures demonstrated a prolific growth of Aspergillus fumigatus and galactomannan was strongly positive. Work-up for ABPA was negative. Therapy with voriconazole was initiated. In 3 weeks, the patient had clinically improved but CT now showed complete collapse of the left upper lobe which persisted at 6 weeks. The left lower lobe however was completely expanded and showed no parenchymal involvement or bronchiectasis. A bronchoscopy was repeated which showed complete obliteration of the left upper lobe with mucous plugs, cultures however were negative. With clinical improvement and laboratory eradication of Aspergillus, voriconazole was continued. At 10 weeks, the patient was completely asymptomatic and CXR showed no abnormalities.

DISCUSSION: Pseudomembranous ATB with tracheobronchial inflammation and ulcerative ATB with bronchial wall ulcerative necrosis have been well described. Obstructive ATB, a rare presentation, is characterized by thick mucous plugs in the airway without macroscopic inflammation. In two previous reports, heart1 and lung2 transplant patients were treated with antifungal therapy. None of these patients demonstrated recurrent atelectasis similar to the present case requiring therapeutic bronchoscopy.

CONCLUSIONS: Obstructive ATB should be promptly recognized and treated with antifungal therapy.

Reference #1: Hummel M, et al. Mycoses 1993;36:425-8.

Reference #2: Cerceo E, et al. J Heart Lung Transplant 2009;28:515-9.

DISCLOSURE: The following authors have nothing to disclose: Tanmay Panchabhai, Debabrata Bandyopadhyay, Abdul Alraiyes, Francisco Almeida

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